Provider Demographics
NPI:1396089439
Name:LIGHTFOOT, JEANIE MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:MARIE
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JEANIE
Other - Middle Name:MARIE
Other - Last Name:LIGHTFOOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3508 366TH ST E
Mailing Address - Street 2:
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-8281
Mailing Address - Country:US
Mailing Address - Phone:540-419-4126
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-968-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAAP60510299367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program